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Intake Form

For best results, please fill this form out on desktop or laptop instead of a mobile device.

Intake Form

Step 1 of 6

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Your Child's Safety is Our Top Priority

In order to ensure the safety of your child during his/her in-home therapy session, it's imperative that an adult be present in your household at all times. While it's not mandatory that a parent/caregiver join the actual session, it can be beneficial.

Note: This form provides developmental milestones and information necessary to better understand your child as we move forward.
Patient Info
Patient Name*
First Last
Nickname
DOB*
MM slash DD slash YYYY
Sex*
- Male
- Female
Address*
Street Address Address Line 2 City State ZIP Code
Apartment #
Name of Apartment Complex or Sub-division
Access/Gate Code
License and Insurance
How would you like to share your License and Insurance information?
- Upload
- Email
Upload a digital copy of your Insurance and License*
You may upload digital copies of the front and back of your insurance card and license here. Allowed files: PDF, Word Docs, JPG, & PNG.
*IMPORTANT: when uploading files, a red X will appear next to your file. This does not mean an error. The X is to remove the file you uploaded in case you upload the wrong file by mistake.
Drop files here or

Accepted file types: doc, docx, jpg, jpeg, pdf, png, Max. file size: 100 MB.
Send a digital copy of your Insurance and License to: [email protected]
Will therapy need to be conducted outside the home?*
I travel to your child at the parent/guardian home. Is there an alternate location outside the home to visit? Eg, daycare, babysitters, church, preschool program?
- Yes
- No
Name of Alternate Location*
Contact Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Referral Questions
Reason for Requesting Services*
Your Child's Specific Diagnosis
How did you learn about Advantage Speech Therapy Services?
- Friend
- Doctor
- Therapist
- Other
Who can we thank for their recommendation?
Parent/Caregiver Info
Parent/Caregiver Name (#1)*
Relationship to Child
DOB*
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone*
Alternate Phone
Alternate Phone Type
- Work
- Cell
- Home
Email
What is the best form of communication to reach you?*
(Check all that apply)
- Select All
- Text
- Cell
- Email
Employment Info #1
- Stay at Home Parent
- Employed
- Unemployed
Is there a second Parent/Caregiver?
- Yes
- No
Employer Info (#1)
Employer Name*
Position
Work Phone*
Work Address*
Street Address Address Line 2 City State ZIP Code
Parent/Caregiver Info (#2)
Parent/Caregiver Name (#2)
Relationship to Child
DOB
MM slash DD slash YYYY
Same address as Parent/Caregiver #1?
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone*
Alternate Phone
Alternate Phone Type
- Work
- Cell
- Home
Email
What is the best form of communication to reach you?*
(Check all that apply)
- Select All
- Text
- Cell
- Email
Employment Info #2
- Stay at Home Parent
- Employed
- Unemployed
Employer Info (#2)
Employer Name*
Position
Work Phone*
Work Address*
Street Address Address Line 2 City State ZIP Code

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Medical
Pediatrician/Primary Doctor Name
Phone
Fax
Address
Street Address Address Line 2 City State ZIP Code
Teletherapy
Teletherapy?*
- Yes
- No
Private Pay?*
- Yes
- No
Insurance
Primary Insurance
DOB*
MM slash DD slash YYYY
Group #
Subscriber’s ID*
Subscriber’s Name
Relationship to Child
Phone
Secondary Insurance Available?*
- Yes
- No
Secondary Insurance
DOB*
MM slash DD slash YYYY
Group #
Subscriber’s ID*
Subscriber’s Name:
Relationship to Child
Phone

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Family Members
Use the + symbol to add additional rows for parent(s)/sibling(s).
Use the + symbol to add additional rows for parent(s)/sibling(s).
Parents Brothers & Ages Sisters & Ages
Please list & describe any Family Members with a history of...
...a known speech, language, fluency and/or hearing concern
Is your child bilingual?
- Yes
- No
What language(s) are spoken in the home?
Child's primary language?
Child's secondary language?

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Child's Communication Style
Please describe your child's difficulty with communicating and how it impacts his/her daily activities
How does your child typically communicate? How does your child express his/her wants and needs?
Check the ones that apply.
- Gesture
- Sign Language
- Grunting
- Talking (select all that apply below:)
- Pointing/Pulling
Talking Styles...
- Jargon/Unintelligible Speech
- Single Words
- Word Combinations
Is your child aware of their difficulty in communicating?
- Yes
- No
How does it impact him/her?
How would you describe your child's ability to speak clearly?
- In error, but understandable
- Difficult to understand
- Requires careful listening
- I don't understand much of what he/she says
Can an unfamiliar listener understand him/her?
- Yes
- No
Does their teacher have trouble understanding him/her?
- Yes
- No
What % do you as the caregiver understand him/her?
Which caregiver are you?
- Mom
- Dad
At what age did your child stop using the pacifier?
At what age did your child stop drinking form a bottle?
Has your child been in therapy before?
- Yes
- No
Specify the Discipline(s)
OT, Speech, PT, ABA or Other
When and with whom did they see?
Has your child had a speech evaluation?
- Yes
- No
Date of Speech Evaluation
MM slash DD slash YYYY
Does your child receive speech in the school?
- Yes
- No
Do they have an active IEP?*
- Yes
- No
Do you have a copy of their IEP to provide ASTS?*
- Yes
- No
I understand that ASTS will need a copy before therapy can be provided.*
- I understand and acknowledge this requirement.
What goals did they address?
(Examples may include: walking, talking, sensory motor, behavior, language)

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Medical History/Milestones
How was the child's mother's health during pregnancy?
Any complications during birth?
- Yes
- No
Describe anything unusual during or immediately following the birth
Has your child been hospitalized?
- Yes
- No
What was the reason?
Does your child take any medication?
- Yes
- No
Please list medication and reason
Does your child have difficulty eating?
- Yes
- No
Please describe their difficulty with eating.
How does your child get along with other children and/or siblings?
At what age did your child... (Please indicate year or month. E.g., 1 year, 7 months, 1 yr 3 mos, etc.)
Crawl
Babble
Dress self
Sit
Use first word
Use toilet
Stand
Use 2+ words
Feed self
Walk
When was the most recent hearing screening and/or evaluation?
MM slash DD slash YYYY
Who conducted the test? Please specify the doctor.
What were the results?
Did your child receive tubes in his/her ears?
- Yes
- No
When?
MM slash DD slash YYYY

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Additional Info
What activities does your child enjoy participating in?
What frustrates your child?
What are his/her strengths?
What are his/her weaknesses?
What would you most like to see your child gain from speech therapy?
Does your child have any known food (or other) allergies?
If so, please specify.
Additional comments:
CAPTCHA
Get a PDF copy of this form emailed to you.
Let us know which email to send a PDF of this form to.
Enter Email Confirm Email
Thank you for taking the time to help us understand your child’s family/medical history, and developmental level.
This information will help us appreciate your child’s strengths and weaknesses in order to address specific goals to increase their communication skills!
Email
This field is for validation purposes and should be left unchanged.

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Tuesday09:00 - 05:00
Wednesday09:00 - 05:00
Thursday09:00 - 05:00
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